MEDICARE: GENE R GARDNER CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist		IL

General Provider Information

NPI Number	:	1710089818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GENE R GARDNER CRNA

Provider Business Mailing Address
First Line	:	4227 LINCOLNSHIRE DR
Second Line	:
City	:	MOUNT VERNON
State	:	IL
Zip	:	62864-2157
Country	:	US
Telephone Number	:	618-242-2317
Fax Number	:	618-242-9710

Provider Business Practice Location Address
First Line	:	605 N 12TH ST
Second Line	:
City	:	MOUNT VERNON
State	:	IL
Zip	:	62864-2857
Country	:	US
Telephone Number	:	618-241-1108
Fax Number	:	618-241-3805

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2006
Last Update Date	:	07/08/2007

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